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Significance\ud \ud Communicating in ways that motivate engagement in social distancing remains a critical global public health priority during the COVID-19 pandemic. This study tested motivational qualities of messages about social distancing (those that promoted choice and agency vs. those that were forceful and shaming) in 25,718 people in 89 countries. The autonomy-supportive message decreased feelings of defying social distancing recommendations relative to the controlling message, and the controlling message increased controlled motivation, a less effective form of motivation, relative to no message. Message type did not impact intentions to socially distance, but people’s existing motivations were related to intentions. Findings were generalizable across a geographically diverse sample and may inform public health communication strategies in this and future global health emergencies.\ud \ud \ud \ud Abstract\ud \ud Finding communication strategies that effectively motivate social distancing continues to be a global public health priority during the COVID-19 pandemic. This cross-country, preregistered experiment (n = 25,718 from 89 countries) tested hypotheses concerning generalizable positive and negative outcomes of social distancing messages that promoted personal agency and reflective choices (i.e., an autonomy-supportive message) or were restrictive and shaming (i.e., a controlling message) compared with no message at all. Results partially supported experimental hypotheses in that the controlling message increased controlled motivation (a poorly internalized form of motivation relying on shame, guilt, and fear of social consequences) relative to no message. On the other hand, the autonomy-supportive message lowered feelings of defiance compared with the controlling message, but the controlling message did not differ from receiving no message at all. Unexpectedly, messages did not influence autonomous motivation (a highly internalized form of motivation relying on one’s core values) or behavioral intentions. Results supported hypothesized associations between people’s existing autonomous and controlled motivations and self-reported behavioral intentions to engage in social distancing. Controlled motivation was associated with more defiance and less long-term behavioral intention to engage in social distancing, whereas autonomous motivation was associated with less defiance and more short- and long-term intentions to social distance. Overall, this work highlights the potential harm of using shaming and pressuring language in public health communication, with implications for the current and future global health challenges.

Background Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no “gold standard” method currently exists. Purpose The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations. Methods PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included. Results Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts. Conclusions Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

Background: The COVID-19 pandemic is a massive health crisis that has exerted enormous physical and psychological pressure. Mental healthcare for healthcare workers (HCWs) should receive serious consideration. This study served to determine the mental-health outcomes of 1,556 HCWs from 45 countries who participated in the COVID-19 IMPACT project, and to examine the predictors of the outcomes during the first pandemic wave. Methods: Outcomes assessed were self-reported perceived stress, depression symptom, and sleep changes. The predictors examined included sociodemographic factors and perceived social support. Results: The results demonstrated that half of the HCWs had moderate levels of perceived stress and symptoms of depression. Half of the HCWs (n = 800, 51.4%) had similar sleeping patterns since the pandemic started, and one in four slept more or slept less. HCWs reported less perceived stress and depression symptoms and higher levels of perceived social support than the general population who participated in the same project. Predictors associated with higher perceived stress and symptoms of depression among HCWs included female sex, not having children, living with parents, lower educational level, and lower social support. Discussion: The need for establishing ways to mitigate mental-health risks and adjusting psychological interventions and support for HCWs seems to be significant as the pandemic continues.

Background Symptom recognition and timely referral in primary care are crucial for the early diagnosis of cancer. Physician assistants or associates (PAs) have been introduced in 18 healthcare systems across the world, with numbers increasing in some cases to address primary care physician shortages. Little is known about their impact on suspected cancer recognition and referral. This review sought to summarise findings from observational studies conducted in high income countries on PAs’ competence and performance on processes concerned with the quality of recognition and referral of suspected cancer in primary care. Method A rapid systematic review of international peer-reviewed literature was performed. Searches were undertaken on OVID, EMBASE, Web of Science, and CINAHL databases (2009–2019). Studies were eligible if they reported on PA skills, processes and outcomes relevant to suspected cancer recognition and referral. Title and abstract screening was followed by full paper review and data extraction. Synthesis of qualitative and quantitative findings was undertaken on three themes: deployment, competence, and performance. Preliminary findings were discussed with an expert advisory group to inform interpretation. Results From 883 references, 15 eligible papers were identified, of which 13 were from the USA. Seven studies reported on general clinical processes in primary care that would support cancer diagnosis, most commonly ordering of diagnostic tests (n = 6) and referrals to specialists (n = 4). Fewer papers reported on consultation processes, such as examinations or history taking (n = 3) Six papers considered PAs’ competence and performance on cancer screening. PAs performed similarly to primary care physicians on rates of diagnostic tests ordered, referrals and patient outcomes (satisfaction, malpractice, emergency visits). No studies reported on the timeliness of cancer diagnosis. Conclusion This review of peer-reviewed literature combined with advisory group interpretation suggests the introduction of PAs into primary care may maintain the quality of referrals and diagnostic tests needed to support cancer diagnosis. It also highlights the lack of research on several aspects of PAs’ roles, including outcomes of the diagnostic process.

Background Many countries consistently fail to achieve the target influenza vaccine coverage rate (VCR) of 75% for populations at risk of complications, recommended by the World Health Organization and European Council. We aimed to identify factors for achieving a high VCR in the scope of four benchmark countries with high influenza VCRs: Australia, Canada, UK and USA. Methods Publicly available evidence was first reviewed at a global level and then for each of the four countries. Semi-structured interviews were then conducted with stakeholders meeting predefined criteria. Descriptive cluster analyses were performed to identify key factors and pillars for establishing and maintaining high VCRs. Results No single factor led to a high VCR, and each benchmark country used a different combination of tailored approaches to achieve a high vaccine coverage. In each country, specific triggers were important to stimulate changes that led to improved vaccine coverage. A total of 42 key factors for a successful influenza vaccination programme were identified and clustered into five pillars: (1) Health Authority accountability and strengths of the influenza programme, (2) facilitated access to vaccination, (3) healthcare professional accountability and engagement, (4) awareness of the burden and severity of disease and (5) belief in influenza vaccination benefit. Each benchmark country has implemented multiple factors from each pillar. Conclusion A wide range of factors were identified from an evaluation of four high-performing benchmark countries, classified into five pillars, thus providing a basis for countries with lower VCRs to tailor their own particular solutions to improve their influenza VCR.

Acute kidney injury (AKI) is a life-threatening complication of rhabdomyolysis. The pathophysiological mechanisms of rhabdomyolysis-induced AKI (RIAKI) have been extensively studied in the murine system, yet clinical translation of this knowledge to humans is lacking. In this study, we investigated the cellular and molecular pathways of human RIAKI. Renal biopsy tissue from a RIAKI patient was examined by quantitative immunohistochemistry (Q-IHC) and compared to healthy kidney cortical tissue. We identified myoglobin casts and uric acid localised to sites of histological tubular injury, consistent with the diagnosis of RIAKI. These pathological features were associated with tubular oxidative stress (4-hydroxynonenal staining), regulated necrosis/necroptosis (phosphorylated mixed-lineage kinase domain-like protein staining) and inflammation (tumour necrosis factor (TNF)-α staining). Expression of these markers was significantly elevated in the RIAKI tissue compared to the healthy control. A tubulointerstitial inflammatory infiltrate accumulated adjacent to these sites of RIAKI oxidative injury, consisting of macrophages (CD68), dendritic cells (CD1c) and T lymphocytes (CD3). Foci of inflammasome activation were co-localised with these immune cell infiltrate, with significantly increased staining for adaptor protein ASC (apoptosis-associated speck-like protein containing a caspase activation and recruitment domain) and active caspase-1 in the RIAKI tissue compared to the healthy control. Our clinical findings identify multiple pathophysiological pathways previously only reported in murine RIAKI, providing first evidence in humans linking deposition of myoglobin and presence of uric acid to tubular oxidative stress/necroptosis, inflammasome activation and necroinflammation.

Introduction Influenza is associated with significant morbidity and mortality worldwide. Whilst vaccination is key for the prevention of influenza infection, there are many factors which may contribute to reduced vaccine effectiveness, including antigenic evolution via both antigenic drift and egg-adaptations. Due to the currently dissociated and indirect evidence supporting both the occurrence of these two phenomena in the egg-based manufacturing process and their effects on vaccine effectiveness, this topic remains a subject of debate. Objective To review the evidence and level of agreement in expert opinion supporting a mechanistic basis for reduced vaccine effectiveness due to egg-based manufacturing, using an expert consensus-based methodology and literature reviews. Methods Ten European influenza specialists were recruited to the expert panel. The overall research question was deconstructed into four component principles, which were examined in series using a novel, online, two-stage assessment of proportional group awareness and consensus. The first stage independently generated a list of supporting references for each component principle via literature searches and expert assessments. In the second stage, a summary of each reference was circulated amongst the experts, who rated their agreement that each reference supported the component principle on a 5-point Likert scale. Finally, the panel were asked if they agreed that, as a whole, the evidence supported a mechanistic basis for reduced vaccine effectiveness due to egg-based manufacturing. Results All component principles were reported to have a majority of strong or very strong supporting evidence (70–90%). Conclusions On reviewing the evidence for all component principles, experts unanimously agreed that there is a mechanistic basis for reduced vaccine effectiveness resulting from candidate influenza virus variation due to egg-based manufacturing, particularly in the influenza A/H3N2 strain. Experts pointed to surveillance, candidate vaccine virus selection and manufacturing stages involving eggs as the most likely to impact vaccine effectiveness.

Background In 2012, the World Health Organization recommended influenza vaccination for all pregnant women worldwide and the prioritisation of pregnant women in national influenza vaccination programmes. Nevertheless, vaccination rates in pregnant women often remain much lower than national targets. Objectives To assess the benefits and risks associated with influenza infection and vaccination during pregnancy, and to consider obstacles that work against influenza vaccine uptake during pregnancy. Results There is strong evidence that maternal and foetal outcomes can be compromised if women develop influenza infections during pregnancy. Influenza vaccines have been administered to millions of pregnant women and have demonstrated benefits in terms of disease prevention in mothers and their infants. There is a consensus amongst several recommending authorities that influenza vaccines may be safely administered during all stages of pregnancy. Healthcare professionals are recognised as the most important influencers of vaccine uptake, being well placed to recommend vaccination and directly address safety concerns. Conclusions Despite data supporting the value of influenza vaccination during pregnancy, vaccine uptake remains low globally. Low uptake appears to be largely due to ineffective communication with pregnant women about the risks and benefits of influenza vaccination. A graphical abstract is available online.

BackgroundIndividual behaviour changes, such as hand hygiene and physical distancing, are required on a population scale to reduce transmission of infectious diseases such as COVID-19. However, little is known about effective methods of communicating risk reducing information, and how populations might respond.ObjectiveTo synthesise evidence relating to what (1) characterises effective public health messages for managing risk and preventing infectious disease and (2) influences people’s responses to messages.DesignA rapid systematic review was conducted. Protocol is published on Prospero CRD42020188704.Data sourcesElectronic databases were searched: Ovid Medline, Ovid PsycINFO and Healthevidence.org, and grey literature (PsyarXiv, OSF Preprints) up to May 2020.Study selectionAll study designs that (1) evaluated public health messaging interventions targeted at adults and (2) concerned a communicable disease spread via primary route of transmission of respiratory and/or touch were included. Outcomes included preventative behaviours, perceptions/awareness and intentions. Non-English language papers were excluded.SynthesisDue to high heterogeneity studies were synthesised narratively focusing on determinants of intentions in the absence of measured adherence/preventative behaviours. Themes were developed independently by two researchers and discussed within team to reach consensus. Recommendations were translated from narrative synthesis to provide evidence-based methods in providing effective messaging.ResultsSixty-eight eligible papers were identified. Characteristics of effective messaging include delivery by credible sources, community engagement, increasing awareness/knowledge, mapping to stage of epidemic/pandemic. To influence intent effectively, public health messages need to be acceptable, increase understanding/perceptions of health threat and perceived susceptibility.DiscussionThere are four key recommendations: (1) engage communities in development of messaging, (2) address uncertainty immediately and with transparency, (3) focus on unifying messages from sources and (4) frame messages aimed at increasing understanding, social responsibility and personal control. Embedding principles of behavioural science into public health messaging is an important step towards more effective health-risk communication during epidemics/pandemics.

Background The COVID-19 pandemic is a massive health crisis affecting our planet, with over 166,346,635 confirmed cases and 3,449,117 deaths globally till 24 May 2021. The COVID-19 pandemic is a massive health crisis which has brought enormous physical and psychological pressure. Mental health care for health care workers (HCWs), should receive serious consideration. The aim of this study was to determine mental health outcomes of HCWs and to examine known predictors of outcomes during the first pandemic wave. Methods 1,556 HCWs who participated in the COVID-19 IMPACT project, an international online survey examining the behavioral and psychological impacts of COVID-19 among 9,565 people from 78 countries/regions and 18 languages. Outcomes assessed were stress, depression symptoms and sleep changes. Predictors examined included sociodemographic factors, and perceived social support. Results Results demonstrated that, half of the HCWs had moderate levels of perceived stress and depression symptoms. Predictors associated with higher HCWs’ stress and depression symptoms included female gender, not having children, living with parents, lower educational background and having lower social support. Half of the HCWs (n = 800, 51.4%) continued to sleep about the same and one in four slept more or slept less. Positive predictors of sleep changes were being older, widower, not working, living with parents, and having children. Surprisingly, HCWs had less perceived stress and depression and higher levels of perceived social support than the general population. Conclusions The need for establishing ways to mitigate mental health risks and adjust psychological intervention and support of HCWs, seems to be significant as the pandemic continues. Keywords: health care workers, COVID – 19, pandemic, mental health, psychological problems

Bile cast nephropathy (BCN) is an underdiagnosed cause of acute kidney injury (AKI). The precise pathogenesis of bilirubin tubular toxicity remains unknown. The aim of this study is to explore the cellular and molecular pathophysiology of human BCN. Paraffin-embedded sections of renal biopsy tissue from a BCN patient were stained by immunohistochemistry (IHC) for oxidative stress (4-hydroxynonenal), immune cell subpopulations, including dendritic cells (CD1c), macrophages (CD68) and T cells (CD3), and inflammasome activation by staining for active-caspase-1 and the inflammasome adaptor protein, ASC (apoptosis-associated speck-like protein containing a caspase activation and recruitment domain). Quantitative analyses of IHC staining were compared to healthy renal cortical tissue. We identified yellow to brown granular casts within the BCN case, consistent with the presence of bile pigment. The presence of bile pigment was associated with strong tubular 4-hydroxynonenal staining intensity, a marker of oxidative stress. Diffuse tubulointerstitial inflammatory cell infiltrate was detected, with elevated CD1c, CD68 and CD3 staining. Foci of inflammasome activity were co-localized with this intense immune cell infiltration, with increased active-caspase-1 and ASC staining. Our findings are the first to suggest that bile casts may lead to oxidative stress and trigger the inflammasome signalling cascade, leading to interstitial inflammation and driving AKI pathobiology. SUMMARY AT A GLANCE The report suggests that bile casts may lead to oxidative stress and trigger the inflammasome signalling cascade, leading to interstitial inflammation and driving bile cast nephropathy pathobiology.

Background Mucosal-associated invariant T (MAIT) cells represent a specialized lymphocyte population associated with chronic inflammatory disorders. Little is known, however, about MAIT cells in diseases of the kidney, including CKD. Methods To evaluate MAIT cells in human native kidneys with tubulointerstitial fibrosis, the hallmark of CKD, we used multicolor flow cytometry to identify, enumerate, and phenotype such cells from human kidney tissue biopsy samples, and immunofluorescence microscopy to localize these cells. We cocultured MAIT cells and human primary proximal tubular epithelial cells (PTECs) under hypoxic (1% oxygen) conditions to enable examination of mechanistic tubulointerstitial interactions. Results We identified MAIT cells (CD3+ TCR Va7.2+ CD161hi) in healthy and diseased kidney tissues, detecting expression of tissue-resident markers (CD103/CD69) on MAIT cells in both states. Tissue samples from kidneys with tubulointerstitial fibrosis had significantly elevated numbers of MAIT cells compared with either nonfibrotic samples from diseased kidneys or tissue samples from healthy kidneys. Furthermore, CD69 expression levels, also an established marker of lymphocyte activation, were significantly increased on MAIT cells from fibrotic tissue samples. Immunofluorescent analyses of fibrotic kidney tissue identified MAIT cells accumulating adjacent to PTECs. Notably, MAIT cells activated in the presence of human PTECs under hypoxic conditions (modeling the fibrotic microenvironment) displayed significantly upregulated expression of CD69 and cytotoxic molecules perforin and granzyme B; we also observed a corresponding significant increase in PTEC necrosis in these cocultures. Conclusions Our findings indicate that human tissue-resident MAIT cells in the kidney may contribute to the fibrotic process of CKD via complex interactions with PTECs.

Chronic kidney disease (CKD) is a clinical syndrome with many adverse sequelae and is currently a major global health and economic burden. Regardless of aetiology, inflammation and fibrosis are common manifestations of CKD. Unfortunately, the underlying pathophysiological mechanisms are poorly understood, and robust prognostic and early diagnostic biomarkers of CKD are lacking. One immune cell population that has received little attention in the context of CKD is mast cells (MCs). This mini review will examine the role of MCs as facilitators of kidney inflammation and fibrosis, propose a mechanistic structure for MCs in CKD, and give consideration to biomarkers specific for MC activation that can be deployed clinically. MCs are derived from haematopoietic stem cells. They are characterised by electron-dense granules in the cytoplasm, filled with preformed mediators. MCs can synthesise a range of bio-active compounds. Activation of MCs modulates an innate immune and adaptive effector response. Increased MC counts have been observed in animal models of kidney disease and a range of kidney diseases in humans where MC presence has been linked to biomarkers of kidney function and tissue damage. To further implicate MCs in CKD, several chemokines, cytokines and proteases released by MCs have been observed in their own right in various kidney diseases and linked to progressive CKD. One compound released by MCs that is of particular interest is the MC-specific protease tryptase. This protease is capable of activating the G-protein coupled receptor (GPCR) protease activated receptor-2 (PAR-2). PAR-2 is widely expressed throughout the kidney and highly expressed in the tubular epithelial cells where its activation induces robust inflammatory and fibrotic responses. Novel prognostic and diagnostic biomarkers of CKD are needed. MC-specific proteases [tryptase, chymase and carboxypeptidase A3 (CPA3)] are easily detectable in the blood but questionably in the urine. This review aims to promote these as prognostic and diagnostic biomarkers in the context of CKD.

The success of large-scale COVID-19 vaccination campaigns is contingent upon people being willing to receive the vaccine. Our study explored COVID-19 vaccine hesitancy and its correlates in eight different countries around the globe. We analyzed convenience sample data collected between March 2020 and January 2021 as part of the iCARE cross-sectional study. Univariate and multivariate statistical analyses were conducted to explore the correlates of vaccine hesitancy. We included 32,028 participants from eight countries, and observed that 27% of the participants exhibited vaccine hesitancy, with increases over time. France reported the highest level of hesitancy (47.3%) and Brazil reported the lowest (9.6%). Women, younger individuals (≤29 years), people living in rural areas, and those with a lower perceived income were more likely to be hesitant. People who previously received an influenza vaccine were 70% less likely to report COVID-19 vaccine hesitancy. We observed that people reporting greater COVID-19 health concerns were less likely to be hesitant, whereas people with higher personal financial concerns were more likely to be hesitant. Our findings indicate that there is substantial vaccine hesitancy in several countries, with cross-national differences in the magnitude and direction of the trend. Vaccination communication initiatives should target hesitant individuals (women, younger adults, people with lower incomes and those living in rural areas), and should highlight the immediate health, social and economic benefits of vaccination across these settings. Country-level analyses are warranted to understand the complex psychological, socio-environmental, and cultural factors associated with vaccine hesitancy.

Half of the mortality in diabetes is seen in individuals DKD risk was assigned in youth with type 1 diabetes [n=100; 20.0±2.8 yrs; M:F-54:46, HbA1C-66.1(12.3) mmol/mol; diabetes duration-10.7±5.2 yrs; BMI-24.5(5.3) kg.m-2] and 10 year historical uACR, HbA1C and random blood glucose concentrations collected retrospectively. Glucose fluctuations in the absence of diabetes were also compared to streptozotocin diabetes in Apolipoprotein E-/- mice. Kidney biopsies were used to examine infiltration of KIM-1 expressing T cells in DKD and compared with other chronic kidney disease. Individuals at high risk for DKD had persistent elevations in uACR (uACRAUC0-10yrs, 29.7±8.8 vs 4.5±0.5; P-1.1.73m-2 higher estimated glomerular filtration rates (eGFRSCHWARTZ; Padj P

Background: Public health teams need to understand how the public responds to vaccination messages in a pandemic or epidemic to inform successful campaigns encouraging the uptake of new vaccines as they become available. Methods: A rapid systematic review was performed by searching PsycINFO, MEDLINE, healthevidence.org, OSF Preprints and PsyArXiv Preprints in May 2020 for studies including at least one health message promoting vaccine uptake of droplet spread viruses. Non-English language studies and dissertations were excluded in line with using rapid review methodology. Included studies were assessed for quality using the MMAT or AMSTAR, and for patient and public involvement (PPI) in designing and/or conducting the research. Results: Thirty-five articles were included. Most reported messages for seasonal influenza (n=11; 31%) or H1N1 (n = 11; 31%) and only seven studies (20%) sampled vulnerable populations at higher risk of mortality/morbidity from viruses, e.g. older adults. Evidence from moderate to high quality studies for improving vaccine uptake included providing: information about virus risks, vaccination safety, and addressing misunderstandings about vaccination, vaccination reminders, detail about vaccination clinics and their locations, and mixed media campaigns at scale across hospitals or communities. Behavioural influences (beliefs and intentions) were improved when shorter messages, risk-reducing, or relative risk framing was used, the benefits of vaccination to society were emphasised, and beliefs about capability to be vaccinated and concerns among target populations (e.g. about vaccine safety) were addressed. Clear, credible, messages in language target groups can understand were found acceptable. Two studies (6%) described PPI in the research process. Conclusions: This review has identified effective messages to encourage vaccination and improve vaccination beliefs and intentions. Future campaigns should consider the beliefs and information needs of target populations in their design. Findings were inconclusive whether the medium through which the message was delivered, e.g. text message, affected outcomes. More high quality research is needed to demonstrate the behavioural outcomes of messaging interventions.

Background: Symptom recognition and timely referral in primary care are crucial for the early diagnosis of cancer. Physician assistants or associates (PAs) have been introduced in 15 healthcare systems across the world, with numbers increasing to address primary care physician shortages. Little is known about their impact on suspected cancer recognition and referral. This review sought to summarise findings from international observational studies on PAs’ competence and performance on processes concerned with the quality of recognition and referral of suspected cancer in primary care. Method: A rapid systematic review of international peer-reviewed literature was performed (PROSPERO reference: CRD42019154114). Searches were undertaken on OVID, EMBASE, Web of Science, and CINAHL databases (2009-2019). Studies were eligible if they reported on PA skills, processes and outcomes relevant to suspected cancer recognition and referral. Title and abstract screening was followed by full paper review and data extraction. synthesis of qualitative and quantitative findings was undertaken on three themes: deployment, competence, and performance. Preliminary findings were discussed with an expert advisory group to inform interpretation. Results: From 876 references, 15 eligible papers were identified, of which 13 were from the USA. Seven studies reported on general clinical processes in primary care that would support cancer diagnosis, most commonly ordering of diagnostic tests (n=6) and referrals to specialists (n=4). Fewer papers reported on consultation processes, such as examinations or history taking (n=3) Six papers considered PAs’ competence and performance on cancer screening. PAs performed similarly to primary care physicians on rates of diagnostic tests ordered, referrals and patient outcomes (satisfaction, malpractice, emergency visits). No studies reported on the timeliness of cancer diagnosis. Conclusion: This review of peer-reviewed literature combined with advisory group interpretation suggests the introduction of PAs into primary care may maintain the quality of referrals and diagnostic tests needed to support cancer diagnosis. It also highlights the lack of research on several aspects of PAs’ roles, including outcomes of the diagnostic process.

BackgroundIn contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity.Methods and resultsCLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009–2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure.Among 32 694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest.ConclusionIn patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes.ClinicalTrials identifierISRCTN43070564

Medication non-adherence (MNA) constitutes a complex health problem contributing to increased economic burden and poor health outcomes. The Medication Adherence Model (MAM) supports that numerous processes are involved in medication adherence (MA). Based on the MAM and guidelines of the World Health Organization (WHO), this scoping review aimed to identify the barriers and facilitators associated with MA, and the behavioral health interventions and techniques among chronic conditions presenting with high non-adherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, and hypertension). PubMed, PsycINFO, and Scopus databases were screened, and 243 studies were included. A mixed methods approach was used to collate the evidence and interpret findings. The most commonly reported barriers to MA across conditions were younger age, low education, low income, high medication cost, side effects, patient beliefs/perceptions, comorbidities, and poor patient–provider communication. Additionally, digitally delivered interventions including components such as medication and condition education, motivational interviewing (MI), and reinforcement and motivational messages led to improvements in MA. This review highlights the importance of administrating multicomponent interventions digitally and personalized to the patients’ individual needs and characteristics, responding to the adherence barriers faced. This is the first review examining and synthesizing evidence on barriers and facilitators to MA and behavioral health interventions used for improving MA across chronic conditions with the highest non-adherence rates and providing recommendations to researchers and clinicians. Stakeholders are called to explore methods overcoming barriers identified and developing effective multicomponent interventions that can reduce the high rates of MNA.

Objective: We aimed to map the resource use during systematic review (SR) production and reasons why steps of the SR production are resource intensive to discover where the largest gain in improving efficiency might be possible., Study design and setting: We conducted a scoping review. An information specialist searched multiple databases (e.g., Ovid MEDLINE, Scopus) and implemented citation-based and grey literature searching. We employed dual and independent screenings of records at the title/abstract and full-text levels and data extraction., Results: We included 34 studies. Thirty-two reported on the resource use-mostly time; four described reasons why steps of the review process are resource intensive. Study selection, data extraction, and critical appraisal seem to be very resource intensive, while protocol development, literature search, or study retrieval take less time. Project management and administration required a large proportion of SR production time. Lack of experience, domain knowledge, use of collaborative and SR-tailored software, and good communication and management can be reasons why SR steps are resource intensive., Conclusion: Resource use during SR production varies widely. Areas with the largest resource use are administration and project management, study selection, data extraction, and critical appraisal of studies., peer-reviewed

Systemic lupus erythematosus (SLE) is a systemic, autoimmune disease that can involve virtually any organ of the body. Lupus nephritis (LN), the clinical manifestation of this disease in the kidney, is one of the most common and severe outcomes of SLE. Although a key pathological hallmark of LN is glomerular inflammation and damage, tubulointerstitial lesions have been recognized as an important component in the pathology of LN. Renal tubular epithelial cells are resident cells in the tubulointerstitium that have been shown to play crucial roles in various acute and chronic kidney diseases. In this context, recent progress has been made in examining the functional role of tubular epithelial cells in LN pathogenesis. This review summarizes recent advances in our understanding of renal tubular epithelial cells in LN, the potential role of tubular epithelial cells as biomarkers in the diagnosis, prognosis, and treatment of LN, and the future therapeutic potential of targeting the tubulointerstitium for the treatment of patients with LN.

Background Online patient simulations (OPS) are a novel method for teaching clinical reasoning skills to students and could contribute to reducing diagnostic errors. However, little is known about how best to implement and evaluate OPS in medical curricula. The aim of this study was to assess the feasibility, acceptability and potential effects of eCREST — the electronic Clinical Reasoning Educational Simulation Tool. Methods A feasibility randomised controlled trial was conducted with final year undergraduate students from three UK medical schools in academic year 2016/2017 (cohort one) and 2017/2018 (cohort two). Student volunteers were recruited in cohort one via email and on teaching days, and in cohort two eCREST was also integrated into a relevant module in the curriculum. The intervention group received three patient cases and the control group received teaching as usual; allocation ratio was 1:1. Researchers were blind to allocation. Clinical reasoning skills were measured using a survey after 1 week and a patient case after 1 month. Results Across schools, 264 students participated (18.2% of all eligible). Cohort two had greater uptake (183/833, 22%) than cohort one (81/621, 13%). After 1 week, 99/137 (72%) of the intervention and 86/127 (68%) of the control group remained in the study. eCREST improved students’ ability to gather essential information from patients over controls (OR = 1.4; 95% CI 1.1–1.7, n = 148). Of the intervention group, most (80/98, 82%) agreed eCREST helped them to learn clinical reasoning skills. Conclusions eCREST was highly acceptable and improved data gathering skills that could reduce diagnostic errors. Uptake was low but improved when integrated into course delivery. A summative trial is needed to estimate effectiveness.

The COVID-19 pandemic has brought with it a great need for the use of telepsychotherapy and other interventions using psychological theories and techniques to support both mental and physical health. E-mental health presents a wide range of opportunities in mental health care to overcome barriers for receiving conventional psychological care, especially when psychotherapists and clients find themselves in (self)quarantine resulting from a pandemic. For many psychotherapists and clients, the current situation provides a first experience with e-mental health and reliance on telepsychotherapy or other means of technology to provide or receive care, respectively. Psychotherapeutic circumstances may often be suboptimal, with psychotherapists and clients experiencing difficulties finding a private space or sufficient time for an undisturbed consultation. This article aims to highlight recommendations on how to create the best possible context in which e-mental health supplements and enhances current services for clients. These recommendations are grouped according to 3 categories of key stakeholders: psychotherapists, health services and regulatory agencies, and developers. This article focuses on (a) how to make optimal use of technology in psychotherapeutic practice; (b) how to integrate e-mental health into the health care system to allow for a safe, transparent, and effective environment for (self) care; and (c) how to develop e-mental health applications.

Seasonal influenza can have serious morbid consequences and can even result in death, particularly in at-risk populations, including healthcare professionals (HCPs), elderly and those living with a medical risk condition. Although in Europe recommendations exist for annual influenza vaccination in these populations in most countries, the vaccination coverage rate (VCR) is often well below the World Health Organization target of 75% coverage. In our previous survey in 2009 we showed that some elements of national vaccination policies, e.g. reminder systems, strong official recommendation, and easy access, seemed to contribute to achieving higher influenza VCRs among elderly. We repeated the survey in 2016, using the same methodology to assess changes in influenza VCRs among the elderly and in the impact of policy elements on these VCRs. In addition, we collected information about VCRs among HCPs, and those living with a medical risk condition. The median VCR in the 21 countries that had recommendations for influenza vaccination in the elderly was 35.3%, ranging from 1.1% in Estonia to 74.5% in Scotland. The average VCRs for HCPs and those living with medical risk conditions, available in 17 and 10 countries, respectively, were 28.3% (range 7% in Czech Republic to 59.1% in Portugal) and 32.2% (range from 20.0% in the Czech Republic and Hungary to 59.6% in Portugal), respectively. Fewer countries were able to provide data from HCP and those living with medical risk conditions. Since the initial survey during the 2007–2008 influenza season, VCRs have decreased in the elderly in the majority of countries, thus, achieving high VCRs in the elderly and the other target groups is still a major public health challenge in Europe. This could be addressed by the identification, assessment and sharing of best practice for influenza vaccination policies.

Purpose: Specialized palliative care (SPC) is currently underutilized or provided late in cancer care. The aim of this systematic review and meta-analysis is to critically evaluate the impact of SPC on patients’ health-related quality of life (HRQoL). Methods: Five databases were searched through June 2016. Randomized controlled trials (RCTs) and prospective studies using a pre- and post- assessment of HRQoL were included. The PRISMA reporting statement was followed. Criteria from available checklists were used to evaluate the studies’ quality. A meta-analysis followed using random-effect models separately for RCTs and non-RCTs. Results: Eleven studies including five RCTs and 2939 cancer patients published between 2001 and 2014 were identified. There was improved HRQoL in patients with cancer following SPC especially in symptoms like pain, nausea, and fatigue as well as improvement of physical and psychological functioning. Less or no improvements were observed in social and spiritual domains. In general, studies of inpatients showed a larger benefit from SPC than studies of outpatients whereas patients’ age and treatment duration did not moderate the impact of SPC. Methodological shortcomings of included studies include high attrition rates, low precision, and power and poor reporting of control procedures. Conclusions: The methodological problems and publication bias call for higher-quality studies to be designed, funded, and published. However, there is a clear message that SPC is multi-disciplinary and aims at palliation of symptoms and burden in line with current recommendations.

In 2012, the Joint Committee on Vaccination and Immunisation recommended that the United Kingdom's (UK) National Vaccination Programme (NVP) for influenza was extended to include healthy children and adolescents aged 2 to17 years. Previously, the UK's NVP focused on seasonal vaccination of the elderly and people (including children) with underlying health conditions that put them at high risk of hospitalisation if they contracted influenza. The extension of the UK's programme began in the 2013/14 influenza season through the vaccination of children aged 2-3 years in primary care across England and the devolved administrations of Scotland, Wales, and Northern Ireland. School-aged children were generally vaccinated in a school setting, with several implementation pilots in England and Scotland. Due to the scale of the programme, it has been phased in over several years and expanded to include broader childhood age groups. This article reviews the experiences from the implementation of the UK's childhood influenza NVP over the first six influenza seasons (between 2013/14 and 2018/19) from the perspectives of England, Scotland, Wales, and Northern Ireland. The processes used to deliver the vaccination programme in general practice and the school-based setting are described in terms of governance, contracting, workforce management, communication, administrative tasks, vaccination sessions, vaccine supply and distribution, and surveillance. In addition, the available evidence regarding the clinical impact of the UK's childhood influenza NVP over the first six influenza seasons is reviewed. We also share lessons learned from the programme and recommendations to provide guidance to other countries looking to implement childhood influenza vaccination programmes.

As the novel coronavirus disease 2019 (COVID-19) pandemic continues, engaging the public in adherence to precautionary measures for preventing COVID-19 spread or infection becomes difficult. The present study aims to extend our understanding of how illness perceptions, coping, and self-efficacy affect adherence to precautionary measures among the public. An online survey was administered between April and June 2020 to a sample of 514 Hong Kong citizens. Variables considered were illness perceptions toward COVID-19, problem-solving, avoidance-based coping, self-efficacy, as well as adherence to precautionary measures including physical distancing, limiting unnecessary travelling, and washing hands regularly with soap and water. Adjusted structural equation model showed that illness perceptions toward COVID-19 had significant direct effect on their adherence to precautionary measures (unstandardized &beta, = 0.50, [95% CI, 0.28, 0.80], p = 0.001), and indirect effects through avoidance-based coping (&beta, = &minus, 0.10 [95% CI, &minus, 0.26, &minus, 0.01], p = 0.016) and self-efficacy (&beta, 0.10, [95% CI, &minus, 0.18, &minus, 0.01], p = 0.025). These results imply that apart from emphasizing the health hazards of a novel infectious disease, an effective public health intervention and crisis communication should address avoidance-based coping and self-efficacy of the public in adherence to precautionary measures for COVID-19.

We investigated and compared current national vaccination policies for health-care personnel (HCP) in Europe with results from our previous survey. Data from 36 European countries were collected using the same methodology as in 2011. National policies for HCP immunization were in place in all countries. There were significant differences in terms of number of vaccinations, target HCP and healthcare settings, and implementation regulations (recommended or mandatory vaccinations). Vaccination policies against hepatitis B and seasonal influenza were present in 35 countries each. Policies for vaccination of HCP against measles, mumps, rubella and varicella existed in 28, 24, 25 and 19 countries, respectively; and against tetanus, diphtheria, pertussis and poliomyelitis in 21, 20, 19, and 18 countries, respectively. Recommendations for hepatitis A immunization existed in 17 countries, and against meningococcus B, meningococcus C, meningococcus A, C, W, Y, and tuberculosis in 10, 8, 17, and 7 countries, respectively. Mandatory vaccination policies were found in 13 countries and were a pre-requisite for employment in ten. Comparing the vaccination programs of the 30 European countries that participated in the 2011 survey, we found that more countries had national vaccination policies against measles, mumps, rubella, hepatitis A, diphtheria, tetanus, poliomyelitis, pertussis, meningococcus C and/or meningococcus A, C, W, Y; and more of these implemented mandatory vaccination policies for HCP. In conclusion, European countries now have more comprehensive national vaccination programs for HCP, however there are still gaps. Given the recent large outbreaks of vaccine-preventable diseases in Europe and the occupational risk for HCP, vaccination policies need to be expanded and strengthened in several European countries. Overall, vaccination policies for HCP in Europe should be periodically re-evaluated in order to provide optimal protection against vaccine-preventable diseases and infection control within healthcare facilities for HCP and patients. (C) 2019 Elsevier Ltd. All rights reserved.

The benefits of exclusive breastfeeding are well documented, yet few women adhere to recommendations. This systematic review reports the Behaviour Change Techniques (BCTs) within interventions trialled internationally after pregnancy to promote exclusive and mixed breastfeeding as well as evidence of effectiveness. PsycINFO, EMBASE and MEDLINE databases were screened. Twenty-three (n = 23) studies met inclusion criteria. Three authors independently extracted data, coded interventions using the BCT v.1 taxonomy, and assessed study quality. There was a moderate significant effect of the interventions promoting exclusive breastfeeding up to four weeks postpartum (OR 1.77, [95% CI: 1.47-2.13]) but this effect slightly declined beyond thirteen weeks (OR 1.63, [95% CI: 1.07-2.47). Twenty-nine BCTs were identified within interventions. ‘Credible source’ and ‘information on how to perform the behaviour’ were the most prevalent and ‘social support (unspecified)’ contributed to the effectiveness of exclusive breastfeeding interventions five to eight weeks postpartum. The use of BCTs covering cognitive and behavioural aspects may help women develop coping mechanisms promoting exclusive breastfeeding. Further trials evaluating interventions are needed in countries with low breastfeeding rates such as the U.K. The use of program theory during intervention development and clear description of intervention components is recommended. This meta-analysis provides guidance for trials evaluating postpartum breastfeeding interventions and information on components for developing interventions.

Objective: Our aim was to assess whether the recommendations and guidelines for thromboprophylaxis in patients with atrial fibrillation (AF) have been adopted in general practice (GP). Methods: We conducted a retrospective study using the GP computer database (Hatfield, UK) on all 9400 patients to assess the quality of anticoagulation in patients with a recorded diagnosis of AF. Results: Of the 180 patients with a diagnosis of AF, 107 (59.4%) were treated with warfarin, 19 (10.6%) with a novel oral anticoagulant (NOAC), 31 (17.2%) with aspirin or clopidogrel, and 23 (12.8%) received none. Thirty-seven patients (34.6%) who were taking warfarin had a time in the therapeutic range (TTR) of less than 65%. Forty-five (27.6%) of the 163 patients who had a CHA2DS2VASc score of two or more were not prescribed a vitamin K antagonist (VKA) or a NOAC. None had a HAS-BLED greater than the CHA2DS2VASc score. Conclusion: Our study demonstrates that one in four patients with non-valvular AF, at risk of a stroke, is not being adequately treated with an oral anticoagulant in primary care. The majority were treated with warfarin, a third of which had a low TTR. A high proportion of patients are prescribed antiplatelet therapy instead. This is despite overwhelming evidence that VKAs and NOACs, and not aspirin or clopidogrel, improve outcome in patients with non-valvular AF. We suggest that a review of GP practice databases should be considered to identify patients with non-valvular AF, at risk of a disabling or fatal event, and measures taken to initiate anticoagulant therapy.

Inflammatory immune cells play direct pathological roles in cases of acute kidney injury (AKI) and chronic kidney disease (CKD). However, the identification and characterization of distinct populations of leukocytes in human kidney biopsies have been confounded by the limitations of immunohistochemical (IHC)-based techniques used to detect them. This methodology is not amenable to the combinations of multiple markers necessary to unequivocally define discrete immune cell populations. We have developed a multi-parameter, flow cytometric-based approach that addresses the need for panels of cell-specific markers in the identification of immune cell populations, allowing both the accurate detection and quantitation of leukocyte subpopulations from a single, clinical kidney biopsy specimen. In this approach, fresh human kidney tissue is dissociated into a single cell suspension followed by antibody-labeling and flow cytometric-based acquisition and analysis. This novel technique provides a major step forward in identifying and enumerating immune cell subpopulations in human kidney disease and is a powerful platform to complement traditional histopathological examinations of clinical kidney biopsies.

A cancer diagnosis is often associated with loss of agency and control that can adversely affect well-being. Patients may try to regain control through dietary change aimed at preventing progression and/or recurrence. Evidence for the effectiveness of post-diagnostic dietary change in prostate cancer is not conclusive, which can cause uncertainty among patients and health professionals. This qualitative study explored how eight men in the U.K., who had been diagnosed with prostate cancer in the previous 5 years, accounted for any post-diagnostic changes they made to their diet. Data were generated through semi-structured telephone interviews and were subjected to thematic analysis. This yielded two themes concerning the perceived nature and importance of dietary change and the perceived determinants of dietary change. The latter focused on internal dimensions such as agency and external dimensions such as the perceived role of relationships with health professionals, the availability of credible dietary information and family influences. The study points to the importance of the family context in enabling the men to implement dietary change. It is suggested that, even if health professionals can only offer qualified, general advice about diet, this may provide men with a focus for action and a means of regaining control.

Background Descriptions of inflammatory cells infiltrating the human kidney rarely mention B cells, other than in the specific scenario of transplantation. In these reports, B cells are localized almost exclusively within the kidney tubulointerstitium where they are ideally placed to interact with proximal tubule epithelial cells (PTEC). We have previously shown that activated PTEC down-modulate autologous T lymphocyte and dendritic cell function. In this report, we extend these prior studies to describe PTEC-B cell interactions. Methods Stimulated B cells were cultured in the absence or presence of activated autologous human PTEC and monitored for proliferation, surface antigen expression, cytokine secretion and antibody (Ab) production. Results PTEC decreased B cell proliferative responses, whilst B cells cultured in the presence of PTEC displayed decreased levels of CD27, a marker of plasma B cells and memory cells. Interestingly, autologous PTEC also significantly decreased the number of B cells secreting both IgG and IgM and overall levels of Ab production. Transwell studies demonstrated that this modulation was primarily contact-dependent, and blocking studies with anti-PD-L1 led to partial restoration in Ab production. Further blocking studies targeting soluble HLA-G (sHLA-G) and IDO, two other immunoinhibitory molecules also up-regulated in our activated PTEC, demonstrated minor restoration of Ab responses. Discussion We report, for the first time, that PTEC are also able to modulate autologous B-cell phenotype and function via complex contact-dependent (PD-L1), soluble (sHLA-G) and intracellular (IDO) factors. We hypothesize that such mechanisms may have evolved to maintain peripheral immune-homeostasis, especially within the inflammatory milieu that exists within many kidney diseases.

BACKGROUND: γδ T cells are effector lymphocytes recognized as key players during chronic inflammatory processes. Mouse studies suggest a pathological role for γδ T cells in models of kidney disease. Here we evaluated γδ T cells in human native kidneys with tubulointerstitial fibrosis, the pathological hallmark of chronic kidney disease. METHODS: γδ T cells were extracted from human kidney tissue and enumerated and phenotyped by multicolour flow cytometry. Localization and cytokine production by γδ T cells was examined by immunofluorescent microscopy. RESULTS: We detected significantly elevated numbers of γδ T cells in diseased biopsies with tubulointerstitial fibrosis compared with diseased biopsies without fibrosis and healthy kidney tissue. At a subset level, only numbers of Vδ1+ γδ T cells were significantly elevated in fibrotic kidney tissue. Expression levels of cluster of differentiation 161 (CD161), a marker of human memory T cells with potential for innate-like function and interleukin (IL)-17A production, were significantly elevated on γδ T cells from fibrotic biopsies compared with nonfibrotic kidney tissue. Flow cytometric characterization of CD161+ γδ T cells in fibrotic biopsies revealed significantly elevated expression of natural killer (NK) cell-associated markers CD56, CD16 and CD336 (NKp44) compared with CD161- γδ T cells, indicative of a cytotoxic phenotype. Immunofluorescent analysis of fibrotic kidney tissue localized the accumulation of γδ T cells within the tubulointerstitium, with γδ T cells identified, for the first time, as a source of pro-inflammatory cytokine IL-17A. CONCLUSIONS: Collectively, our data suggest that human effector γδ T cells contribute to the fibrotic process and thus progression to chronic kidney disease.

Longer life expectancy and decreasing fertility rates mean that the proportion of older people is continually increasing worldwide, and particularly in Europe. Ageing is associated with an increase in the risk and severity of infectious diseases. These diseases are also more difficult to diagnose and manage in seniors who often have at least one comorbid condition (60% of seniors have two or more conditions). Infectious diseases increase the risk of hospitalization, loss of autonomy and death in seniors. Effective vaccines are available in Europe for infectious diseases such as influenza, pneumococcal diseases, herpes zoster, diphtheria, tetanus and pertussis. Their effectiveness has been demonstrated in terms of reducing the rates of hospitalization, disability, dependency and death. The prevention of diseases in seniors also results in savings in healthcare and societal costs each year in Europe. Despite the availability of vaccines, vaccine-preventable diseases affect millions of European citizens annually, with the greatest burden of disease occurring in seniors, and the medical and economic benefits associated with are not being achieved. Vaccination coverage rates must be improved to achieve the full benefits of vaccination of seniors in Europe.

This article aims to investigate associations between perceived control and health-related quality of life (HRQOL) with dietary changes after prostate cancer diagnosis and to explore General Practitioners’ (GPs) perceptions on the role of diet in prostate cancer post-diagnosis. Ninety-five prostate cancer patients completed measures of dietary change, one for after diagnosis and another for after therapy. They also scored their HRQOL and perceived control. There were discrepancies in dietary changes reported between a general question (28.4% no dietary changes) and a specific (42.1%– 51.5% range of no change for various food items). Most patients initiated healthy changes. Patients who changed their diet after diagnosis had lower cognitive functioning and external locus of control (doctors). Patients who changed their diet after therapy had lower cognitive and emotional functioning, quality of life and external locus of control (doctors). Then, fourty-four GPs responded to an online survey. Their open-ended responses were analysed using Content Analysis. They reported interest in the role of diet in cancer but also lack of relevant knowledge. They were skeptical on providing information. Clinical interventions should consider patients’ cognitive ability, their relationship with their health professional and their wellbeing. Also, GPs’ confidence to provide dietary advice needs to be addressed.

BACKGROUND: Melanoma incidence is rising rapidly worldwide among white populations. Defining higher-risk populations using risk prediction models may help targeted screening and early detection approaches. OBJECTIVES: To assess the feasibility of identifying people at higher risk of melanoma using the Williams self-assessed clinical risk estimation model in U.K. primary care. METHODS: We recruited participants from the waiting rooms of 22 general practices covering a total population of > 240 000 in three U.K. regions: Eastern England, North East Scotland and North Wales. Participants completed an electronic questionnaire using tablet computers. The main outcome was the mean melanoma risk score using the Williams melanoma risk model. RESULTS: Of 9004 people approached, 7742 (86%) completed the electronic questionnaire. The mean melanoma risk score for the 7566 eligible participants was 17·15 ± 8·51, with small regional differences [lower in England compared with Scotland (P = 0·001) and Wales (P < 0·001), mainly due to greater freckling and childhood sunburn among Scottish and Welsh participants]. After weighting to the age and sex distribution, different potential cut-offs would allow between 4% and 20% of the population to be identified as higher risk, and those groups would contain 30% and 60%, respectively of those likely to develop melanoma. CONCLUSIONS: Collecting data on the melanoma risk profile of the general population in U.K. primary care is both feasible and acceptable for patients in a general practice setting, and provides opportunities for new methods of real-time risk assessment and risk stratified cancer interventions.

IntroductionSocial media platforms offer unique opportunities for health promotion messages focusing on cancer prevention and early diagnosis. However, there has been very little synthesis of the evaluation of such campaigns, limiting the ability to apply learning to the design of future social media campaigns. We aimed to provide a broad overview of the current research base on social media interventions for cancer prevention and early diagnosis, to identify knowledge gaps and to inform policy, practice and future research questions.MethodsWe will use scoping review methodology to explore the available evidence on social media interventions for cancer prevention and early diagnosis, with a focus on methodological approaches. Quantitative and qualitative studies and reports will be identified through searching several research databases, through internet searching for grey literature and by screening the citations of studies included in the review. All identified studies will undergo independent title and abstract screening and full-text screening against inclusion and exclusion criteria. We plan to chart the data from included studies to record the characteristics of the social media interventions, resources, activities, outputs, outcomes and impact. Charted data will be collated and summarised using a narrative synthesis. The interpretation and implications of the findings will be enhanced by consultation with relevant stakeholders such as public health organisations, cancer charities, and patient and public involvement groups when preliminary results are available.Ethics and disseminationEthical approval is not required for this scoping review. The results will be used to identify research questions for future systematic reviews and to inform the development of future social media interventions. We will disseminate findings in peer-reviewed journals and at relevant conferences.

Sharpsnout seabream Diplodus puntazzo has been successfully introduced in Mediterranean aquaculture for reasons of species diversification. However, there is limited information related to specific rearing conditions that the species may require for production optimization in land-based aquaculture. The aim of the present study was to investigate the combined effects of rearing density and background colour on growth performance of sharpsnout sea bream D. puntazzo reared in a recirculating water system. Juveniles (4.0 ± 0.03 g) were reared (duplicated groups) under low (D 16 fish tank−1 or 1 kg m−3) and high (3D 48 fish tank−1 or 3 kg m−3) density in white, light blue and black tanks for 88 days. During the first 53 days of rearing, fish under low density presented better growth than fish under high density. However, in the following period (days 53–88) SGR in 3D-reared fish was significantly higher than in D-reared fish, resulting in no mass differences on day 88. Regardless of rearing density effects, black tanks had a negative effect on growth and should be avoided in sharpsnout sea bream rearing. Within the life stage studied, present growth results, along with those of fish groups homogeneity (coefficient of mass variation, frequency distribution of mass), indicate a change in social interactions according to body size. It is suggested that juvenile sharpsnout seabream should be stocked at low density until they reach approximately 16 g. Afterwards, a higher density seems more appropriate for this species while it also ensures a higher productivity.

Background: Atrial fibrillation (AF) management represents a significant burden on the UK NHS. Understanding this burden will be important in informing future health care planning and policy development. Aim: To describe the non-anticoagulation costs associated with AF management in routine UK clinical practice. Materials, patients and methods: A retrospective observational study of 825 patients with AF undertaken in eight UK primary care practices. Data collected from routine clinical and prescribing records of all eligible, consenting patients, for a period of up to 3 years. The first 12 weeks following diagnosis was defined as the ‘initiation phase’; the period after week 12 was defined as the ‘maintenance phase’. Results: Mean (SD) total cost of AF management was £941 (£1094) per patient in the initiation phase and £426 (£597) per patient-year in the maintenance phase. AF-related inpatient admissions contributed most to total costs; the mean (SD) total cost per patient in the initiation phase was £2285 (£900) for admitted and £278 (£252) for non-admitted patients. Mean maintenance phase costs per year were £1323 (£755) and £168 (£234), respectively, for admitted and non-admitted patients. Significant patient variables contributing to high cost in the initiation phase were hypertension and younger patient age, although only accounting for 6% of cost variability. Significant variables in the maintenance phase (18% of cost variability) were the presence of congestive heart failure, structural heart disease or diabetes and the frequency of day case admissions, ECGs and hospitalisations in the initiation phase. Conclusions: Inpatient admissions contributed most to total AF management costs. Given the burden of hospital care, future work should focus on evaluating the appropriateness and reasons for hospitalisation in patients with AF and the factors affecting length of stay, with the aim of identifying opportunities to safely reduce inpatient costs. A number of significant patient characteristics and initiation phase variables were identified, which accounted for 18% of the variability in total maintenance phase costs. However, none of these could adequately predict high maintenance phase costs.

Background Annual vaccination is the most effective way to prevent and control the health and economic burden caused by seasonal influenza. Healthcare workers (HCWs) play a crucial role in vaccine acceptance and advocacy for their patients. This study explored the drivers of HCWs’ vaccine acceptance and advocacy in six European countries. Methods Healthcare workers (mainly general practitioners, specialist physicians, and nurses) voluntarily completed a questionnaire in Bulgaria (N = 485), Czech Republic (N = 518), Kosovo (N = 466), Poland (N = 772), Romania (N = 155), and the United Kingdom (N = 80). Twelve-item scales were used to analyse sentiment clusters for influenza vaccination acceptance and engagement with vaccination advocacy. Past vaccination behaviour and patient recommendation were also evaluated. All data were included in a single analysis. Results For vaccination acceptance, the main cluster (engaged sentiment: 68%) showed strong positive attitudes for influenza vaccination. A second cluster (hesitant sentiment: 32%) showed more neutral attitudes. Cluster membership was predicted by country of origin and age. The odds ratio for past vaccination in the engaged cluster was 39.6 (95% CI 12.21–128.56) although this varied between countries. For vaccination advocacy, the main cluster (confident sentiment: 73%) showed strong positive attitudes towards advocacy; a second cluster (diffident sentiment: 27%) showed neutral attitudes. Cluster membership was predicted by country of origin, age and profession, with specialist physicians being the least likely to belong to the confident sentiment cluster. HCWs characterised by confident advocacy sentiments were also more likely recommend flu vaccination. Again, this association was moderated by country of origin. Conclusions These data show that there is room to improve both vaccination acceptance and advocacy rates in European HCWs, which would be expected to lead to higher rates of HCW vaccination. Benefits that could be expected from such an outcome are improved advocacy and better control of morbidity and mortality related to seasonal influenza infection.